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					                                                                                AIDS epidemic update: December 2005
                                                                                                          Caribbean




                                          CARIBBEAN

           HIV and AIDS statistics and features, in 2003 and 2005

             Adults and            Number of          Adults and children          Adult          Adult and
            children living       women living        newly infected with       prevalence       child deaths
               with HIV             with HIV                  HIV                  (%) *         due to AIDS

    2005        300 000              140 000                 30 000                  1.6             24 000
            [200 000 – 510 000]   [88 000–250 000]        [17 000–71 000]          [1.1–2.7]      [16 000–40 000]


    2003        300 000              140 000                 29 000                  1.6             24 000
            [200 000–510 000]     [87 000–250 000]        [17 000–68 000]          [1.1–2.7]      [16 000–40 000]




The AIDS epidemic claimed an estimated 24 000              understanding of recent epidemiological trends in
[16 000–40 000] lives in the Caribbean in 2005,            some countries. Unfortunately, this applies also
making it the leading cause of death among                 to countries which, in the past, have recorded
adults aged 15–44 years. A total of 300 000                alarming levels of HIV infection among pregnant
[200 000–510 000] people are living with HIV               women, including Bahamas and French Guiana.
in the Caribbean, including the 30 000 [17 000–            The reasons for such shortcomings include
71 000] people who became infected in 2005. In             resource constraints but reluctance among public
the Caribbean Community (CARICOM) region                   officials to publicize the scale of their AIDS
240 000 [150 000–450 000] people are living                epidemics might be a factor as well.
with HIV, including the 25 000 [12 000–65 000]
people who acquired the virus in 2005. More than           The region’s epidemics are driven primarily by
20 000 [13 000–36 000] people died of AIDS in              heterosexual intercourse (the documented mode
the past year in this region.1                             of transmission in three quarters or more of all
                                                           AIDS cases reported to date), with commercial
The Caribbean’s status as the second-most affected         sex a prominent factor, against a backdrop
region in the world masks substantial differences          of severe poverty, high unemployment and
in the extent and intensity of its epidemics.              gender inequalities. In-depth research on the
Estimated national adult HIV prevalence surpasses          interplay between the sex industry and HIV
1% in Barbados, Dominican Republic, Jamaica                transmission, however, remains comparatively
and Suriname, 2% in the Bahamas, Guyana and                limited in the Caribbean. Even more infrequent
Trinidad and Tobago, and exceeds 3% in Haiti.              is acknowledgement of the significant role sex
In Cuba, on the other hand, prevalence is yet to           between men plays in many Caribbean countries’
reach 0.2%.
                                                           epidemics. The overall share of reported HIV
While a few countries have made progress in                infections attributed to sex between men is
monitoring and dealing with their epidemics,               approximately 12%, but homophobia and robust
inadequate HIV surveillance hampers a detailed             sociocultural taboos that stigmatize same sex


1
 CARICOM comprises: Antigua and Barbuda, the Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica,
Montserrat, Saint Lucia, St. Kitts and Nevis, St. Vincent and the Grenadines, Suriname, Trinidad and Tobago.


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UNAIDS/WHO




relations mean that the actual proportion could be                               partly accounts for such discrepancies, but also
somewhat larger (Inciardi et al., 2005). Injecting                               important is the relatively common practice of
drug use is responsible for a small minority of                                  younger women establishing relationships with
HIV infections currently; only in Bermuda and                                    older men (who, by virtue of their age, are more
Puerto Rico does it contribute significantly to the                               likely to have acquired HIV). In some countries,
spread of HIV.                                                                   sexual activity begins comparatively early—when
                                                                                 surveyed, one quarter of 15–29 year-old women
New HIV infections among women are surpassing                                    in Barbados said they had been sexually active
those among men. Young women in particular                                       by the time they turned 15. And almost one third
face considerably higher odds of becoming                                        of men aged 15–29 years reported multiple sexual


                             Several recent developments in the Caribbean give cause
                                              for guarded optimism.
infected than do young men. In Trinidad and                                      partnerships in the previous year, according to
Tobago, for example, HIV infection levels are                                    the same survey (Caribbean Technical Expert
six times higher among 15–19 year-old females                                    Group, 2004). Such trends are likely to provide
than among males of the same age (Inciardi et                                    the epidemic with momentum.
al., 2005). Earlier studies indicated that women
younger than 24 years in the Dominican Republic                                  At the same time, several recent developments
were almost twice as likely, and teenage girls in                                in the Caribbean give cause for guarded
Jamaica were two-and-a-half times more likely                                    optimism. Haiti’s epidemic, one of the oldest
to be HIV-infected, compared with their male                                     in the world, could be turning a corner. Overall,
counterparts (MAP, 2003). Girls’ and young                                       the percentage of pregnant women testing HIV-
women’s physiological susceptibility to infection                                positive reduced by half from 1993 to 2003-2004


 Figure 17


                             HIV prevalence at consistent selected antenatal clinic
                                      surveillance sites, Haiti 1993–2004

                                                All women             Urban women              Semi-urban, rural women
                        12


                        10
     % HIV prevalence




                        8


                        6


                        4


                        2


                        0
                                      1993                       1996                      2000                       2004
                                                                              Year

                        Source: Ministère de la Santé Publique et de la Population, Analyse secondaire des études de sero surveillance
                        par méthode sentinelle de la prévalence du VIH chez les femmes enceintes en Haϊti entre 1993 et 2004




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                                                                               AIDS epidemic update: December 2005
                                                                                                         Caribbean




     Is Haiti turning a corner?
     HIV prevalence among pregnant women in Haiti generally has decreased since the mid-1990s, but
     the trends in urban and rural parts of the country have shown distinct differences. Data from five
     sentinel sites (distributed across the country) with comparable data from 1993 to 2003-2004 show
     HIV prevalence dropping steeply from 9% to 3.7% among urban women. Data for 1996 to 2003-
     2004 from a further nine sites also show a pronounced decline in HIV infection levels among urban
     women, from 8% to 4% (Gaillard et al., 2004b). This suggests that HIV prevalence in urban areas
     possibly peaked in the mid-1990s before gradually declining. However, among semi-urban and
     rural women, the changes are much less evident. For them, HIV prevalence at the five sites with
     comparable data was only slightly lower in 2003-2004 compared with 1993 (2.6% versus 3.5%).
     What might account for these trends? On the one hand, a significant proportion of Haitians has
     reported changing their sexual behaviour. In 2000, almost twice as many men and women said
     they were abstaining from sex, for example, compared with 1994 (11% versus just under 7%). In
     addition, more people said they were remaining with one partner (45% of men and 32% of women
     in 2000, compared to 37% and 20%, respectively, in 1994).
     On the other hand, there is evidence of behaviour change that could signal greater risk of HIV
     transmission. For example, young Haitians are becoming sexually active at earlier ages. Median
     ages at first sex was 19.8 years for men and 18.3 years for women in 1994; six years later, the
     ages were 18.2 years for men and 17.5 years for women (Gaillard et al., 2004b). Correspondingly,
     the percentage of 15–19 year-olds who say they have never had sex decreased to 66% for women
     and 48% for men in that age group (compared to 71% and 53%, respectively, in 1994) (Gaillard et
     al, 2004b). Condom use among young Haitians (15–24 years) has also decreased. Just 28% of
     young Haitian women (15–24 years) in 2003 said they had used a condom the last time they had
     sex, as did 37% of men of the same age. It might be that older Haitians have been taking greater
     precautions to avoid HIV infection. The declines in HIV prevalence appear to be more pronounced
     among women older than 24 years of age.
     However, AIDS mortality very likely accounts for a substantial share of the observed drop in infection
     levels. If AIDS deaths are helping drive HIV prevalence lower, the comparatively slight decline in
     infections levels seen in rural areas could imply that HIV incidence there is still marked. In that
     case, considerable numbers of people would be acquiring HIV while AIDS also kills large numbers
     of people—causing the overall number of people living with HIV to stay stable or decline slightly.
     In addition, the sociopolitical upheavals of recent years could be generating conditions (such as
     displacement, social instability and livelihood insecurity) that allow for more rapid spread of HIV.
     There is no guarantee, therefore, that the decrease in HIV prevalence observed in urban areas
     will continue or extend into rural areas without strong, sustained HIV prevention programmes.
     Such efforts should take account of the fact that HIV prevalence among pregnant women varies
     considerably (ranging from 1.8% to almost 7% in different parts) (Ministère de la santé publique et
     de la population Haïti et al., 2004).




(from 6.2% to 3.1%). The trend has been most              HIV in the Caribbean (an estimated 173 000 in
pronounced in urban areas (where HIV prevalence           2004) (Gaillard et al., 2004a), intensification of
fell from 9.4% in 1993 to 3.7% in 2003-2004),             HIV prevention is imperative in the country.
and especially among 15–24 year-olds—which                Sharing the island of Hispaniola with Haiti is
suggests that a significant slowing down of new            the Dominican Republic, which appears also to
HIV infections could be occurring in the country’s        be seeing some rewards as a result of its AIDS
cities (Gaillard et al., 2004b). The decline appears      response. HIV infections levels in pregnant
to be associated with some behavioural change.            women have been declining since the late 1990s,
AIDS mortality is almost certainly an important           with overall HIV prevalence in pregnant women
contributing factor (see box). In rural areas, the        roughly stable at the 1.4% measured in the
decline has been much more modest. Since Haiti            2004 round of sentinel surveillance. However,
still has the largest number of people living with        in some sites (such as San Juan de la Maguana)


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UNAIDS/WHO




HIV prevalence at antenatal clinics was 2.7%         Public Health The Bahamas, 2004). Enhanced
(Secretaria de Estado de Salud Pública y             clinical management and treatment of AIDS
Asistencia Social de Republica Dominica,             at the community level has drastically reduced
2005b). In the capital Santo Domingo, HIV            mother-to-child transmission of HIV. It has
prevalence among pregnant women was                  likely also contributed to the declining number of
1.3% at the main antenatal clinic in 2004, a         annual deaths attributable to AIDS in the country
significant change from the over 2% found in          (from 272 in 2000 to 185 in 2003) (Caribbean
1995 (Secretaria de Estado de Salud Pública y        Epidemiology Centre, PAHO, WHO, 2003). It is
Asistencia Social de Republica Dominica, 2005b;      estimated that at least 30% of persons with HIV
UNAIDS/WHO, 2004). However, HIV infection            were receiving appropriate clinical management
levels among pregnant women are considerably         at community clinics in 2003.
higher in other parts of the country: 2.3% in San
Juan, in the west, and 2.5% in La Romana, in         Stepped-up efforts to confront the smaller
the east, for example. And in some bateyes (the      epidemic in Barbados also appear to be paying
impoverished communities of mainly Haitian           dividends. New HIV diagnoses among pregnant
workers that service sugar cane mills), infection    women decreased by half between 1999 and 2003
levels of 5.5% in men and 4.7% among women           (with prevalence slipping from 0.7% to 0.3%)
have been found.                                     (Kumar and Singh, 2004), while the expansion
                                                     of voluntary counselling and testing services, and
Low HIV infection levels of 3–4% found among         provision of antiretroviral prevention regimens
sex workers in Santo Domingo probably reflect         has reduced mother-to-child transmission of
efforts to encourage consistent condom use and       HIV (St John et al., 2003). Wider access to
other safer behaviours in their ranks. When          antiretroviral treatment cut AIDS deaths by half
surveyed in the capital, 87% of sex workers          in 1998–2003, a trend also witnessed in Bermuda
reported using a condom the last time they had       in 2000–2002 (Caribbean Epidemiology Centre,
sold sex, and 76% said they always used a condom     2004; Caribbean Epidemiology Centre, PAHO,
during paid sex (Ministerio de Salud de Republica    WHO, 2003).
Dominica, 2005a). As in other Caribbean
                                                     In Jamaica, most HIV infections are occurring
countries, sex between men seems to be playing a
                                                     in urban areas, with the parishes of Kingston,
significant, though inadequately recognized role
                                                     St. Andrew, and St. James worst-affected. HIV
in the Dominican Republic’s epidemic. A recent
                                                     prevalence among pregnant women has remained
study in three cities (Puerto Plata, Samana and
                                                     at 1–2% since the mid-1990s, although recent
Santo Domingo) among men who have sex with
                                                     HIV surveillance at antenatal clinics suggests
men found 11% of them were living with HIV
                                                     that prevalence might be declining slightly in
(Toro-Alfonso and Varas-Diaz, 2004) In another
                                                     parts of the country (the parishes of St. Ann
study, about one third of men who have sex with
                                                     and St. James, for example) (Ministry of Health
men said they had also slept with women in the
                                                     Jamaica, 2004). There are some signs that a
previous six months—and only half of them said
                                                     large proportion of Jamaicans take precautions
they had used a condom during that period.
                                                     to protect themselves against HIV infection.
HIV-infection levels have declined in the            In surveys over the past decade, about three
Bahamas, indicating that improved HIV                quarters of men have said they used a condom
prevention efforts could be responsible for part     the last time they had sex with a casual partner.
of that trend. Newly reported HIV infections         The percentage of women reporting the same
decreased from 409 in 2000 to 275 in 2003 (a         behaviour almost doubled from 1992–2000
32% decline), while HIV prevalence measured          (Caribbean Technical Expert Group, 2004). As
in pregnant women followed a similar path,           in Jamaica, unprotected heterosexual intercourse
(dropping from 4.8% in 1993 to 3% in 2002);          is the driving factor in the epidemic in Trinidad
HIV levels among patients at sexually                and Tobago, where estimated national adult
transmitted infection clinics also fell (Caribbean   HIV prevalence edged past 3% in 2003. A
Technical Expert Group, 2004; Department of          recently-published study among women giving




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                                                                                                 AIDS epidemic update: December 2005
                                                                                                                           Caribbean




birth in Tobago found 2.6% of them were HIV-                            Just under 2% of adult Surinamese were living
positive; among those younger than 25 years,                            with HIV at the end of 2003. New registered HIV
prevalence was 3.8%. A very large percentage                            cases have increased threefold since the mid-
of women were also infected with HSV2, a                                1990s (104 in 1996 to 371 in 2003), but much
sexually transmitted infection which, as studies                        of that trend is probably due to increased testing.
in Africa have shown, greatly enhances the risk                         High levels of HIV infection found in men who
of HIV transmission (Duke et al., 2004; Weis et                         have sex with men (7% in a 2005 study) indicate
al., 2001).                                                             that sex between men features in Suriname’s
                                                                        epidemic; previous research indicated that about
Guyana and Suriname are experiencing serious                            one third of men who have sex with men also had
epidemics. National HIV prevalence in Guyana                            sexual relationships with women (CAREC/PAHO,
was estimated at 2.5% at the end of 2003, and                           2005b; Del Prado et al., 1998). HIV knowledge
AIDS has become the leading cause of death                              appears to be high among men who have sex with
for people aged 25–44 years (UNAIDS/WHO,                                men (about 80% of the men knew at least three
2004). The steep rise in officially-reported HIV                         ways of protecting themselves against infection).
cases reported over the past decade suggests a                          Although 70% of the men said they always
worsening epidemic, with high HIV prevalence                            used a condom during commercial sex, another
having been recorded among men and women                                study found that more than one in three male
attending sexually transmitted infection clinics                        sex workers were HIV-positive (CAREC/PAHO,
(15% for men and 12% for women in 2002)                                 2005a and 2005b). Given that among female sex
(Caribbean Technical Expert Group, 2004).                               workers HIV prevalence is also very high (21%,
However, HIV information is limited outside the                         according to a 2005 study), commercial sex work
country’s cities, making it difficult to gauge the                       likely plays a central role in Suriname’s epidemic
actual extent of the epidemic.                                          (CAREC/PAHO, 2005b).

Figure 18



                     Reported number of HIV and AIDS cases, Cuba 1986–2003*

                     900
                     800                     HIV Cases      AIDS Cases
                     700
   Number of Cases




                     600
                     500
                     400
                     300
                     200
                     100
                      0
                           1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
                                                                       Year


        *Extrapolations from reported cumulative number of cases as of end 2003 for the years 2002 and 2003 and years with no report

        Source: Caribbean Technical Expert Group (2004). Strengthening the Caribbean regional response to the HIV/AIDS
        epidemic: Report of the Caribbean Technical Expert Group on HIV Prevention and Gender. Draft working document.
        October. Jamaica




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UNAIDS/WHO




Cuba’s epidemic remains by far the smallest in the     to be achieved and sustained in the Caribbean.
Caribbean, with adult HIV prevalence estimated         Lacking in particular is reliable, up-to-date
to be less than 0.1% (Caribbean Technical Expert       information about behaviour patterns and trends
Group, 2004). However, new HIV infections              among at-risk sections of the population such as
are on the rise, and Cuba’s preventive measures        sex workers and men who have sex with men, and
appear not to be keeping pace with conditions          the ways in which the behaviours might feature
that favour HIV spread, including widening             in HIV transmission. The continuing shortage
income inequalities and a growing sex industry         of good quality HIV surveillance data stands in
(Camara et al., 2003; Inciardi et al., 2005). At       the way of potentially effective HIV prevention
the same time, Cuba’s prevention of mother-to-         programmes and will hinder the effectiveness
child transmission programme remains highly            of the antiretroviral treatment roll-outs, which
effective. All pregnant women are tested for HIV,      remain highly uneven in this region. While
and those testing positive receive antiretroviral      universal treatment access is being achieved
drugs. As a result of this policy and overall low      in Cuba, and coverage is relatively high in the
infection rates, fewer than 20 HIV-infected babies     Bahamas and Barbados, access to treatment
had been born by 2004 (Susman, 2003; Caribbean         is poor in three of the worst-affected countries
Technical Expert Group (2004). In addition,            in the Caribbean. About one third of people in
universal, free access to antiretroviral therapy has
                                                       need of antiretroviral treatment were receiving
kept the number of AIDS cases and deaths low.
                                                       it in Trinidad and Tobago in September 2005,
Improved HIV and behavioural surveillance is           as were a mere 12% in Haiti and 10% in the
essential if effective prevention strategies are       Dominican Republic (PAHO, 2005).




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